Marian Adult Care Home

Based on documentation review, record review, and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery for three of five sampled staff. The deficient practice posed a risk if facility staff were not properly trained to assist a resident who had fallen, was uninjured, and was unable to recover independently. The deficient practice posed a risk as the designated standards were not followed. Findings include: 1. A review of E1's, E2's, and E3's personnel records reported no documentation of fall prevention and fall recovery training. 2. In an interview, E1 acknowledged there was no documentation to reflect E1, E2, and E3 received training in fall prevention and fall recovery.

Based on record review and interview, the manager failed to ensure individuals employed by the facility completed documentation of a negative Mantoux skin test or other tuberculosis screening test that was recommended by the U.S. Centers for Disease Control and Prevention (CDC) for two of five sampled employees. Findings include: 1. According to the CDC’s website (https://www.cdc.gov/tb/hcp/testing-diagnosis/tuberculin-skin-test.html), “Two-step testing if the first TB (tuberculosis) skin test result is negative, a second TB skin test should be done 1 to 3 weeks later.” 2. A review of E2’s and E3‘s personnel records contained no documentation that a second TB test was completed. 3. In an interview, E2 acknowledged that there was no documentation of a second test for E2 and E3 available for review during the survey.

Based on observation and documentation review, the manager failed to designate, in writing, a caregiver who was present on the assisted living facility’s premises and accountable for the assisted living facility when the manager was not present on the assisted living facility premises. Findings include: 1. Upon arrival of the compliance officer, E1 was observed to be E1 to be the only personnel on the premises; E2 and E3 arrived at the facility later during the survey. 2. A review of documentation reported a document titled “Delegation of Manager’s Authority” dated October 29, 2024, which did not report that E1 was designated as a manager's designee. 3. In an interview, E2 acknowledged the manager failed to designate, in writing, a caregiver who was present on the assisted living facility’s premises and accountable for the assisted living facility when the manager was not present on the assisted living facility's premises.

Based on record review and interview, the manager failed to ensure policies and procedures were implemented to protect the health and safety of a resident, which covered orientation and in-service education for employees and volunteers. Findings include: 1. A review of documentation of the facility’s policies and procedures stated “the manager shall ensure that a caregiver and assistant caregiver completes a minimum of 6 hours of ongoing training every 12 months from the starting date of employment”. 2. A review of E2’s and E4’s personnel records (both hired in August 2022) did not contain documentation of six hours of continuing education every 12 months from the start date of E2’s and E4’s employment. 3. In an interview, E2 acknowledged policies and procedures were not implemented to protect the health and safety of a resident

Based on documentation review, record review, and interview, the manager failed to ensure a manager, a caregiver, or an assistant caregiver complied with the fingerprinting requirements in A.R.S. § 36-411 for one of five sampled personnel records. Findings include: 1. A.R.S. § 36-411(C) states: " C. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card. 3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee." 2. A review of E5's personnel record did not contain verification that E5 was not on the adult protective services registry pursuant to section 46-459. 3. In an interview, E1 reviewed and acknowledged that E5's personnel record did not contain verification that E5 was not on the adult protective services registry pursuant to section 46-459.

Based on record review and interview, the manager failed to ensure a caregiver’s skills and knowledge were verified and documented before the caregivers provided physical health services, for two of four sampled caregivers. Findings include: 1. A review of the facility’s document titled “Delegation of Authority” dated October 29, 2024 reflected E3 and E5 were designated to be responsible for the facility in the manager’s absence. 2. A review of R1’s and R2’s August 2025 medication administration record (MAR) documented E3 and E5 administered R1’s and R2’s medications. 3. A review of the personnel records of E3 and E5 did not contain documentation that their skills and knowledge were verified before E3 and E5 provided physical health services. 4. In an interview, E2 acknowledged there was no documentation available of E3’s and E5’s skills and knowledge being verified and documented before E3 and E5 provided physical health services.

Based on record review and interview, the manager failed to ensure that a resident's service plan that was documented and implemented was signed and dated by the manager, and the nurse or medical practitioner who reviewed the service plan, for one of two sampled residents. Findings include: 1. A review of R1's medical record contained a service plan dated July 23, 2024, which reported R1 received medication administration services. R1's August 2025 medication administration record reflected that R1's medication was administered by various staff. R1's service plan was not signed and dated by the manager and the nurse or medical practitioner who reviewed the service plan. 2 . In an interview, E2 reviewed and acknowledged that R1's service plan was not signed and dated by the manager and the nurse or medical practitioner who reviewed the service plan at the time of the survey.

Based on observation, record review, and interview, the manager failed to ensure for an assisted living home, a resident's sleeping area was on the ground floor of the assisted living home unless the resident was ambulatory without assistance. Findings include: 1. A review of R1's medical record contained a service plan dated July 23, 2025, which stated "Mobility/transfer one-assist... Assertive device walker". 2. A review of R2's medical record contained a service plan (date not written), which reported R2 was non-ambulatory. 3. The compliance officer observed R1 using a walker. The compliance observed R1's room to be located on the second floor of the facility. The compliance officer observed E2 assisting R2 with using the facility's stair lift to ambulate to the first floor. 4. The compliance officer observed R2 using a wheelchair to ambulate on the first floor of the facility. R2 was observed using the facility's stair lift to get to the facility's second floor. The compliance officer observed E2 assisting R2 with using the facility's stair lift. 5. In an interview, E1 reported R1 uses a walker and R2 uses a wheelchair to ambulate, and that they both reside on the facility's second floor. 6 . In an interview, E1 acknowledged that R1's and R2's sleeping areas were not on the ground floor of the assisted living home, and that R1 and R2 were not ambulatory without assistance.